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www.zora.uzh.ch

Year: 2015

All-ceramic or metal-ceramic tooth-supported fixed dental prostheses

(FDPs)? A systematic review of the survival and complication rates. Part I:
Single crowns (SCs)

Sailer, Irena; Makarov, Nikolay Alexandrovich; Thoma, Daniel Stefan; Zwahlen, Marcel; Pjetursson,
Bjarni Elvar

Abstract: OBJECTIVE To assess the 5-year survival of metal-ceramic and all-ceramic tooth-supported
single crowns (SCs) and to describe the incidence of biological, technical and esthetic complications.
METHODS Medline (PubMed), Embase, Cochrane Central Register of Controlled Trials (CENTRAL)
searches (2006-2013) were performed for clinical studies focusing on tooth-supported fixed dental pros-
theses (FDPs) with a mean follow-up of at least 3 years. This was complimented by an additional hand
search and the inclusion of 34 studies from a previous systematic review [1,2]. Survival and complica-
tion rates were analyzed using robust Poisson’s regression models to obtain summary estimates of 5-year
proportions. RESULTS Sixty-seven studies reporting on 4663 metal-ceramic and 9434 all-ceramic SCs
fulfilled the inclusion criteria. Seventeen studies reported on metal-ceramic crowns, and 54 studies re-
ported on all-ceramic crowns. Meta-analysis of the included studies indicated an estimated survival rate
of metal-ceramic SCs of 94.7% (95% CI: 94.1-96.9%) after 5 years. This was similar to the estimated 5-
year survival rate of leucit or lithium-disilicate reinforced glass ceramic SCs (96.6%; 95% CI: 94.9-96.7%),
of glass infiltrated alumina SCs (94.6%; 95% CI: 92.7-96%) and densely sintered alumina and zirconia
SCs (96%; 95% CI: 93.8-97.5%; 92.1%; 95% CI: 82.8-95.6%). In contrast, the 5-year survival rates
of feldspathic/silica-based ceramic crowns were lower (p<0.001). When the outcomes in anterior and
posterior regions were compared feldspathic/silica-based ceramic and zirconia crowns exhibited signifi-
cantly lower survival rates in the posterior region (p<0.0001), the other crown types performed similarly.
Densely sintered zirconia SCs were more frequently lost due to veneering ceramic fractures than metal-
ceramic SCs (p<0.001), and had significantly more loss of retention (p<0.001). In total higher 5 year
rates of framework fracture were reported for the all-ceramic SCs than for metal-ceramic SCs. CONCLU-
SIONS Survival rates of most types of all-ceramic SCs were similar to those reported for metal-ceramic
SCs, both in anterior and posterior regions. Weaker feldspathic/silica-based ceramics should be limited
to applications in the anterior region. Zirconia-based SCs should not be considered as primary option
due to their high incidence of technical problems.

DOI: https://doi.org/10.1016/j.dental.2015.02.011

Posted at the Zurich Open Repository and Archive, University of Zurich

ZORA URL: https://doi.org/10.5167/uzh-110791
Journal Article
Accepted Version

Originally published at:

Sailer, Irena; Makarov, Nikolay Alexandrovich; Thoma, Daniel Stefan; Zwahlen, Marcel; Pjetursson,
Bjarni Elvar (2015). All-ceramic or metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A
systematic review of the survival and complication rates. Part I: Single crowns (SCs). Dental Materials,
31(6):603-623.
DOI: https://doi.org/10.1016/j.dental.2015.02.011

2
All-ceramic or metal-ceramic tooth- supported fixed dental
prostheses (FDPs)?
A systematic review of the survival and complication rates.
Part I: Single crowns (SCs)

Irena Sailer1, Nikolay Alexandrovich Makarov1, Daniel Stefan Thoma2, Marcel

Zwahlen3, Bjarni Elvar Pjetursson4

1) Division for Fixed Prosthodontics and Biomaterials, Center of Dental

Medicine, University of Geneva, Geneva, Switzerland.
2) Department of Fixed and Removable Prosthodontics and Dental Material
Science, University of Zurich, Switzerland.
3) Department of Social and Preventive Medicine, University of Berne, Berne,
Switzerland.
4) Department of Reconstructive Dentistry, Faculty of Odontology, University
of Iceland, Reykjavik, Iceland.

Corresponding address:
Irena Sailer, Prof. Dr.
Division of Fixed Prosthodontics and Biomaterials
Center of Dental Medicine
University of Geneva
19, rue Barthelemy-Menn
CH 1205 Geneva, Switzerland
Irena.sailer@unige.ch
Phone: +41 22 379 4050

Running head: Systematic review of all-ceramic and metal-ceramic crowns

Key words: All-ceramic, single crowns, systematic review, survival, success,

longitudinal, failures, complication rates, technical complications, biological
complications.

1
Abstract
Objective: to assess the 5-year survival of metal-ceramic and all-ceramic
tooth-supported single crowns (SCs) and to describe the incidence of
biological, technical and esthetic complications.
Methods: Medline (PubMed), Embase, Cochrane Central Register of
Controlled Trials (CENTRAL) searches (2006-2013) were performed for
clinical studies focusing on tooth-supported fixed dental prostheses (FDPs)
with a mean follow-up of at least 3 years. This was complimented by an
additional hand search and the inclusion of 34 studies from a previous
systematic review [1, 2]. Survival and complication rates were analyzed using
robust Poisson’s regression models to obtain summary estimates of 5-year
proportions.
Results: Sixty-seven studies reporting on 4663 metal-ceramic and 9434 all-
ceramic SCs fulfilled the inclusion criteria. Seventeen studies reported on
metal-ceramic crowns, and 54 studies reported on all-ceramic crowns. Meta-
analysis of the included studies indicated an estimated survival rate of metal-
ceramic SCs of 95.7% (95% C.I.: 94.1%-96.9%) after 5 years. This was
similar to the estimated 5-year survival rate of leucit or lithium-disilicate
reinforced glass ceramic SCs (96.6%; 95% C.I.: 94.9%-96.7%), of glass
infiltrated alumina SCs (94.6%; 95 % C.I.: 92.7%-96%) and densely sintered
alumina and zirconia SCs (96%; 95% C.I.: 93.8%-97.5%; 92.1%; 95% C.I.:
82.8-95.6%). In contrast, the 5-year survival rates of feldspathic/silica-based
ceramic crowns were lower (p<0.001). When the outcomes in anterior and
posterior regions were compared feldspathic/silica-based ceramic and
zirconia crowns exhibited significantly lower survival rates in the posterior
region (p<0.0001), the other crown types performed similarly. Densely
sintered zirconia SCs were more frequently lost due to veneering ceramic
fractures than metal-ceramic SCs (p<0.001), and had significantly more loss
of retention (p<0.001). In total higher 5 year rates of framework fracture were
reported for the all-ceramic SCs than for metal-ceramic SCs.
Conclusions: Survival rates of most types of all-ceramic SCs were similar to
those reported for metal-ceramic SCs, both in anterior and posterior regions.
Weaker feldspathic/silica-based ceramics should be limited to applications in

2
the anterior region. Zirconia-based SCs should not be considered as primary
option due to their high incidence of technical problems.

3
Introduction

All-ceramic fixed dental prostheses (FDPs) are considered an established

treatment alternative to metal-ceramic FDPs in daily clinical practice. The
main reason to use of the all-ceramics instead of metal-ceramics is based on
more favorable esthetics [3]. All-ceramic materials mimic very naturally the
optical properties of teeth. Another more recent factor influencing the choice
of materials and leading to an increasing use of all-ceramics is treatment
costs, mostly due to the pronounced raise of the costs for high precious
metals like gold [4].
The main shortcoming of the firstly introduced ceramics like e.g. feldspathic
glass ceramic, yet, was low mechanical stability, which limited the indications
for all-ceramic reconstructions to anterior regions and to single-unit FDPs [1].
In the past years, numerous new dental ceramic materials were developed
with the aim to increase the overall stability of the all-ceramic reconstructions,
while still maintaining the esthetic benefit. Among those materials, leucite or
lithium-disilicate leucit or lithium-disilicate reinforced glass ceramics and oxide
ceramics such as alumina and zirconia appeared to be very promising for
different indications. Reconstructions made of these more recently developed
ceramics were placed at posterior sites and even included multiple-unit FDPs
[5].
Subsequently performed clinical studies confirmed the assumption that these
more mechanically more stable ceramic materials would perform better than
the firstly developed ones when used for tooth-borne FDPs. The clinical
outcomes of the more recent ceramics were far better than the ones of the
first generation of dental ceramics [1, 2]. A systematic review of the literature
demonstrated significantly higher survival rates of SCs e.g. made out of leucit
or lithium-disilicate reinforced glass ceramics compared to SCs made out of
feldspathic ceramics (95.4% vs. 87.5%). Tooth-borne SCs made out of
densely sintered alumina exhibited the highest survival rates (96.4%)
compared to all other all-ceramic SCs. Furthermore, all-ceramic crowns
exhibited similar survival rates as metal-ceramic crowns (93.3% vs. 95.6%)
[1]. In conclusion, improvements in terms of material properties such as
mechanical stability of the ceramics had a positive effect on the clinical
outcomes of all-ceramic reconstructions.

4
The clinical follow-up of the studies on all-ceramic FDPs, however, was rather
short. At time of the above-mentioned systematic review a limited amount of
studies was available, most of the published studies did not exceed 5 years of
clinical follow-up. In order to be able to draw clinical conclusions with respect
to the outcomes of all-ceramic reconstructions, more clinical research with
longer observation periods was needed. In addition, the available clinical
research indicated that despite of all material improvements catastrophic
fractures remained to be one major issue of all-ceramic reconstructions. In
addition, this problem was more often found in the posterior region, or for
multiple-unit FDPs where high load occurred [1].

Hence, until recently, it was not possible to recommend all-ceramic single or

multiple-unit FDPs as clinically equivalent treatment alternative to metal
ceramic FDPs. Metal- ceramics remained to be the “gold standard” type of
reconstruction. Yet, a high number of new manuscripts of all-ceramic and
metal-ceramic single- and multiple-unit FDPs was published since the
previously mentioned systematic review. The more recent studies either
reported on the all-ceramic or metal-ceramic FDPs analyzed before but with
longer observation periods, or on new all-ceramic FDPs made out of improved
ceramic materials.
Therefore, the aim of the present systematic review was to analyze the
outcomes of all-ceramic and metal-ceramic FDPs, i.e. of single crowns and of
multiple-unit FDPs, and to assess whether or not all-ceramic FDPs achieve
similar long-term results as FDPs made out of metal-ceramics.

The objectives of this systematic review, therefore, were:

1) To update the previous systematic review [1] on tooth-supported FDPs

with an additional literature search including retrospective and prospective
studies from 2007 to 2013

2) To obtain overall robust estimates of the long-term survival and

complication rates of all-ceramic crowns over an observation period of at least
3 years.

3) To compare the survival and complication rates of all-ceramic crowns with

the ones of metal-ceramic crowns (gold standard).

5
The present part 1 of the review presents the outcomes of all-ceramic versus
metal-ceramic single crowns. Part 2 of the review analyzed the outcomes of
the multiple-unit FDPs.

6
Materials and methods

Search strategy and study selection

The present review followed the same search methodology as the previous
one [1].

Focused questions

“What are the survival and complication rates of tooth-supported FDPs after a
mean observation period of at least 3 years?” “Are the survival and
complications rates of metal-ceramic and all-ceramic tooth-supported FDPs
similar after a mean observation period of at least 3 years?”

PICO

The population, intervention, comparison and outcomes, i.e. the “PICO” for
this systematic review was defined as follows:
Population: Subjects with anterior and\or posterior tooth-supported fixed
dental prostheses [FDP].
Intervention: All-ceramic FDPs
Comparison: Metal-ceramic FDPs
Outcomes: Clinical survival rates, and technical and\or biological complication
rates.
A literature search in databases PubMed, Embase, Cochrane Central
Register of Controlled Trials (CENTRAL) search was performed. The search
was limited to human studies in dental journals written in English language.
Articles published from 1st of December 2006 up to and including the 31st of
December 2013 were included. The following detailed search terms were
used and the search strategy was as follows:

P and I: crowns[MeSH] OR crown[MeSH] OR dental crowns[MeSH] OR

crowns, dental[MeSH] OR Denture, Partial, Fixed[Mesh])) OR (crown*[all
fields] OR fixed partial denture*[all fields] OR FPD[all fields] OR FPDs[all
fields] OR fixed dental prosthesis[all fields] OR fixed dental prostheses[all
fields] OR FDP[all fields] OR FDPs[all fields] OR bridge*[all fields]

7
C: ceramic[MeSH] OR ceramics[MeSH] OR metal ceramic
restorations[MeSH])) OR (ceramic*[All Fields] OR all-ceramic[all fields] OR
Dental Porcelain[All Fields] OR metal-ceramic[All Fields]
O: survival[Mesh] OR survival rate[Mesh] OR survival analysis[Mesh] OR
dental restoration failure[Mesh] OR prosthesis failure[Mesh] OR treatment
failure[Mesh].
The combination in the builder was set as “P & I AND C AND O”.

The electronic search was complemented by manual searches of the

bibliographies of all full text articles and related reviews, selected from the
electronic search. The search was independently performed by two
researches (IS and NAM). Any disagreement was resolved in consensus
between the authors.
Up to the level of data extraction, the literature was evaluated for both single
crowns and multiple- unit FDPs at the same time. At full text level the
manuscripts were split according to the reconstruction type.

Inclusion criteria

Besides the mentioned RCTs, this systematic review was based on

prospective or retrospective cohort studies, or case series.

The additional inclusion criteria for study selection were:

• studies with a minimum mean follow-up period of 3 years.

• included patients had been examined clinically at the follow-up visits,

i.e. publications based on patient records only, on questionnaires or
interviews were excluded.

• studies reported details on the characteristics of the reconstructions, on

materials and methods and on the results.

• studies had to include and follow-up at least 10 patients.

• publications which combined findings of tooth and implant supported

reconstructions where at least 90% was tooth supported
reconstructions.

8
The final selection based on inclusion/exclusion criteria was made for the full
text articles. For this purpose Materials and Methods, Results and Discussion
of these studies were screened. This step was again carried out by 2 readers
(IS, NAM) and double-checked. Any questions that came up during the
screening were discussed to aim for consensus.

Exclusion criteria

The following study types were excluded

• in-vitro or animal studies.

• studies with less than 3 years of follow-up

• studies based on chart reviews or interviews

Selection of studies

Titles and abstracts of the searches were independently screened by two

reviewers (IS & NAM) for possible inclusion in the review. Furthermore, the
full text of all studies of possible relevance was then obtained and split into
literature on single crowns (part 1 of the review) and literature on multiple-unit
FDPs (part 2 of the review).

The literature on single crowns was independently assessed by three of the

reviewers (IS, BEP & NAM). Any disagreement regarding inclusion was
resolved by discussion.

Data extraction

Data on the following parameters were extracted: author(s), year of

publication, study design, planned number of patients, actual number of
patients at end of study, drop-out rate, mean age, age range, operators,
material framework, brand name of framework material, veneering material,
brand name of veneering material, type of manufacturing procedure, number
of FDPs, number of abutment teeth, number of (non)vital abutment teeth,
number of pontics, location of FDP (anterior, posterior, maxilla, mandible),
reported mean follow-up, follow-up range, published FDP survival rate,
number of FDPs lost (anterior, posterior), reported biological complications

9
(caries, periodontal, root fracture), reported technical complications
(framework fracture, minor chipping, major chipping, loss of retention),
esthetic complications (marginal discoloration), reported number of patients
free of complications. Based on the included studies, the FDP survival rate
was calculated. In addition, the number of events for all technical, biological
and esthetic complications was extracted and the corresponding total
exposure time of the reconstruction was calculated.

Data was extracted independently by two reviewers (IS & NAM) using a data
extraction form. Disagreement regarding data extraction was resolved by
consensus of three reviewers (IS, BEP & NAM).

Statistical analysis

For the statistical analysis the new data of the present review, encompassing
the 33 studies was combined with the previous data of the 34 studies
published in Pjetursson et al. 2007.

Hence, the data included in the present analysis was published from 1990
until the end of 2013.

Survival was defined as the FDP remaining in-situ with or without modification
for the observation period.

Failure and complication rates were calculated by dividing the number of

events (failures or complications) in the numerator by the total FDP exposure
time in the denominator.

The numerator could usually be extracted directly from the publication. The
total exposure time was calculated by taking the sum of:

1) Exposure time of FDPs that could be followed for the whole

observation time.

2) Exposure time up to a failure of the FDPs that were lost due to failure
during the observation time.

3) Exposure time up to the end of observation time for FDPs that did not
complete the observation period due to reasons such as death, change

10
 of address, refusal to participate, non-response, chronic illnesses,
missed appointments and work commitments.

For each study, event rates for the FDPs were calculated by dividing the total
number of events by the total FDP exposure time in years. For further
analysis, the total number of events was considered to be Poisson distributed
for a given sum of FDP exposure years and Poisson regression with a
logarithmic link-function and total exposure time per study as an offset
variable were used [6].

Robust standard errors were calculated to obtain 95 % confidence intervals of

the summary estimates of the event rates. To assess heterogeneity of the
study specific event rates, the Spearman goodness-of-fit statistics and
associated p-value were calculated. If the goodness-of-fit p-value was below
0.05 five year survival proportions were calculated via the relationship
between event rate and survival function S, S(T)= exp(-T *event rate), by
assuming constant event rates [7]. The 95 % confidence intervals for the
survival proportions were calculated by using the 95 % confidence limits of
the event rates. Multivariable Poisson regression was used to formally
compare construction subtypes and to assess other study characteristics. All
analyses were performed using Stata®, version 13.1.

11
Results

From this extensive new search, one randomized controlled clinical trial (RCT)
was available comparing all-ceramic single crowns with conventional metal-
ceramic crowns [8]. This RCT compared zirconia-based SCs with metal-
ceramic SCs [8]. No further RCT comparing all-ceramic and metal-ceramic
crowns was available. However, one RCT compared crowns made of
feldspathic ceramic and glass-infiltrated alumina [9]. Finally, one RCT
compared two types of metal-ceramic crowns [10].

Figure 1 describes the process of identifying the 71 full text articles selected
from an initial yield of 580 titles that were found published in the period from
the 1st of December 2006 to the 31st of December 2013.

From these, 41 full text articles were allocated to the “single crown” group,
whereas 37 were allocated to the group reporting on “multiple-unit FDPs”.

Study characteristics

Included Studies

The final number of the new studies included in the analyses resulted as 33
studies. Information on the survival proportions of the single crowns was
extracted from these included 33 studies. In addition, the data from 34
publications from the previous systematic review [1] was included in the
analyses.
The details on the previously included studies as well as the references are
given in Pjetursson et al. 2007, and in tables 1 and 2. The newly included 33
studies on all-ceramic and/or metal-ceramic single crowns were published
between 2006 and 2013 (Tables 1 and 2).
Out of these studies, 4 were designed as RCTs. However, only one RCT
compared all-ceramic (zirconia-based) and metal-ceramic crowns. All other
RCTs compared either two different types of all- ceramics or of metal-
ceramics, or all-ceramic and resin-based single crowns.
Furthermore, 14 “new” studies were reporting on metal-ceramic crowns, 4 on
crowns made out of feldspathic/ silica-based ceramics (jacket crowns, 3G

12
OPC, Noritake feldspathic, Dicor), 6 on reinforced glass- ceramic crowns (1
study on Empress 1 [11], the remaining on Empress 2 or E.max ), 3 on glass-
infiltrated alumina crowns (InCeram), 3 on densely sintered alumina crowns
(Procera) and, finally, 8 on densely sintered zirconia crowns (various
CAD/CAM manufacturing procedures). (Table 1)
The studies included patients between the age of 17 and 81. The proportion
of patients who could not be followed for the complete study period was
available for 27 studies and ranged from 0% to 66%. (Tables 1 and 2)

Excluded Studies

During the full-text evaluation of the total of 41 single crown studies, 8 were
excluded. Two articles (Ortorp et al. 2009 and Walton et al. 2009) were
multiple publications on the same patient cohorts and were, therefore,
excluded. Three manuscripts (Mansour et al. 2008, Groten et al. 2010 and
Rinke et al. 2011) reported on observation periods of less than 3 years. One
study (Cagidiaco et al. 2008) gave no detailed information on crown material
and did not report on the details of the outcomes. In one study (Silva et al.
2011) the reported data was not specified between implant and tooth
abutments, single crowns and bridges. The last study (Burke et al. 2009) was
based on a chart review and, therefore, was excluded.

Crown survival

Overall, in the 17 studies reporting on metal-ceramic crowns with a mean

follow-up of 7.3 years an estimated annual failure rate of 0.88 was reported,
translated into an estimated 5-year survival of metal-ceramic crowns of
95.7%. In comparison, all-ceramic crowns had an annual failure rate ranging
between 0.69 and 1.96, translating into overall estimated 5-year survival rates
ranging between 90.7% and 96.6%. This was based on 55 studies on all-
ceramic crowns included in the analysis. (Table 3)

The survival rates of all-ceramic crowns differed for the various types of
ceramics. Ten studies reported on the first types of feldspathic/ silica based
ceramics and rendered an estimated 5-year survival rate of 90.7%. This

13
survival rate was significantly lower than the one reported for the gold-
standard, metal- ceramic crowns. (Tables 3 and 4)

The 12 studies reporting on leucit or lithium-disilicate reinforced glass

ceramics showed an estimated 5- year survival rate of 96.6%, which was
similar to the survival rate of metal-ceramic crowns. The same applied for
crowns made out of glass- infiltrated alumina (15 studies with an estimated 5-
year survival of 94.6%) and out of densely sintered alumina (8 studies with an
estimated 5-year survival of 96.0%). (Tables 3 and 4, Figs. 2-7)

SCs made out of zirconia had a significantly lower estimated 5-year survival
rate compared to metal-ceramic crowns (p=o.o5). The zirconia- based crowns
reached an estimated 5- year survival rate of 91.2%. (Tables 3 and 4, Fig. 7)

Anterior vs. posterior regions

When the outcomes of anterior and posterior single crowns were compared
no statistically significant differences of the survival rates were found for
metal-ceramic crowns, and for leucit or lithium-disilicate reinforced glass
ceramic crowns, alumina and zirconia based crowns (p>0.05).

Crowns made out of feldspathic or silica based ceramics, however, exhibited

significantly lower survival rates in the posterior region than in the anterior
(87.8% vs. 94.6%, p<0.0001). (Table 5)

Technical and biological complications

Tables 6 and 7 display an overview of the incidences, the estimated annual

complication rates and the cumulative complication rates of technical and
biological complications for metal-ceramic SCs and the different types of all-
ceramic crowns, as well as the statistical differences between the crown
types.

Technical complications

14
Framework fracture, ceramic fracture, ceramic chipping, marginal
discoloration, loss of retention and poor esthetics were technical problems
reported for single crowns.

Ceramic chipping was a common problem, and overall occurred similarly for
metal-ceramics and at the all-ceramic crowns. Furthermore, for metal-
ceramic crowns, ceramic chipping was the most frequent technical
complication with a cumulative 5-year event rate of 2.6% (95% CI: 1.3%-
5.2%). For all-ceramic crowns a tendency to more chippings of the veneering
ceramic was observed for alumina and zirconia- based SCs than for all other
ceramic crowns.

Framework fracture rarely occurred for metal-ceramic crowns (cumulative 5-

year complication rate 0.03%; 95% CI 0.002%- 0.3%) (Table 7). Overall, this
problem occurred significantly more often for ceramic crowns, irrespective of
the type of ceramic used (p<.0001, p=.03) (Table 6). The incidence of
framework fracture was associated with the mechanical stability of the
ceramic material. Weaker ceramics like early feldspathic/ silica based
ceramics exhibited a high 5-year framework fracture rate of 6.7% (95% CI
2.4%- 17.7%). For leucit or lithium-disilicate reinforced glass ceramics
framework fractures occurred at a rate of 2.3% (95% CI 1.0%- 5.5%) of the
crowns and for zirconia- based single crowns at a rate of 0.4% only (95% CI
0.1%- 1.7%).

With the exception of zirconia- based crowns, loss of retention was not a
predominant technical problem. Zirconia based crowns exhibited significantly
more loss of retention than metal ceramic crowns (estimated 5-year
complication rate 4.7%; 95% CI 1.7%- 13.1%) (p<.0001). (Tables 6 and 7)

Biological complications

Loss of abutment tooth vitality, abutment tooth fracture and secondary caries
were the predominantly reported as biologic complications for SCs.
For metal- ceramic crowns loss of abutment tooth vitality was the most
frequent biologic complication (5-year complication rate 1.8%; 95% CI 1.6%-
1.8%). This problem less frequently occurred for leucit or lithium-disilicate

15
reinforced glass ceramic and glass- infiltrated alumina crowns (p=.006,
p<.0001).
In addition, abutment tooth fracture was also predominantly found for metal-
ceramic crowns (5-year complication rate 1.2%; 95% CI 0.7%- 2.0%). This
complication occurred significantly less frequently for all-ceramics like leucit or
lithium disilicate reinforced glass ceramics, glass infiltrated alumina or at
zirconia- ceramics (p=.009, p= .04, p=.02).
Finally, secondary caries was reported for 1% of metal-ceramic crowns (95%
CI 0.8% - 1.4%) after 5 years in function. Most all-ceramic crowns exhibited
similar 5-year caries rates as metal-ceramic SCs. However, zirconia based
crowns had significantly less secondary caries, and glass-infiltrated ceramic
crowns had higher caries rates (p=.04, p<.0001). (Tables 6 and 7)

16
Discussion

The present systematic review showed that the 5-year survival rates of all-
ceramic crowns made out of leucit or lithium-disilicate reinforced glass
ceramics or the oxide ceramics alumina and zirconia exhibited similar survival
rates as the gold standard, metal ceramic crowns. This was not the case,
however, for feldspathic/ silica based ceramic SCs. Crowns made out of these
rather weak ceramics exhibited significantly higher failure rates compared to
metal-ceramic crowns.
The same observation was made when the outcomes of the crowns in
anterior and posterior regions were compared. Metal- ceramic crowns and all-
ceramic crowns out of leucit or lithium-disilicate reinforced glass ceramics or
oxide ceramics performed similarly in anterior and posterior regions. However,
weaker feldspathic/ silica- based ceramics and glass- infiltrated alumina
exhibited significantly lower survival rates in the posterior region than in the
anterior.
Technically, catastrophic framework fracture was the main complication of the
all-ceramics, this problem was most specifically found when weaker ceramic
materials were used [12]. With respect to the non- catastrophic technical
complications, chipping of the veneering ceramic was a main clinical issue
both found at the metal- ceramic as well as at the all-ceramic crowns [13].
Another technical problem observed was loss of retention, which was most
frequently reported for zirconia- based single crowns [14].
Biologically, all-ceramic single crowns seemed to perform better than the gold
standard, metal- ceramic crowns. Significantly more loss of abutment tooth
vitality and abutment tooth fracture was reported for metal-ceramic crowns.
These biologic complications might impair the prognosis of the abutment tooth
or even lead to its loss and a loss of the reconstruction. In comparison, these
complications were rarely reported for the all-ceramic crowns.

At the time the previous systematic review was published by the same
authors in 2007, limited scientific data was available in the literature on a
number of materials. Still, the review already indicated favorable outcomes of
all-ceramic single crowns made out of more recently developed reinforced
ceramics and oxide ceramics [1]. The review, furthermore, displayed

17
limitations of mechanically weaker all ceramic crowns. The gold standard
metal- ceramics, interestingly, was not well documented [1].

In the present review, 14 new studies on metal-ceramics were available as

well as a high number of new studies evaluating all-ceramic crowns. The
results of the present review, hence, may be considered more robust with
more impact for the daily clinical practice.
In the present review it was shown that all-ceramic crowns made of leucit or
lithium- disilicate reinforced glass ceramics or alumina based oxide ceramics
can be recommended as an alternative treatment option to the gold standard
metal-ceramics for SCs in anterior and posterior regions. The less stable
feldspathic/ silica glass ceramics can only be recommended in the anterior
region.
The review also indicated that zirconia based single crowns performed less
well in the clinics, despite the enhanced mechanical stability of this oxide
ceramic. Failure due to extensive fracture of the veneering ceramic and loss
of retention were frequently found technical problems for this type of ceramic
crowns, occurring more often than at the other types of all-ceramics. Chipping
of the veneering ceramic and loss of retention were technical complications
also reported for multiple-unit zirconia based FDPs [15-17], occurring
significantly more often at the zirconia- based FDPs than at metal- ceramics
[18]. The more recent clinical studies showed that despite all developments
and efforts for the improvement of the veneering procedures of zirconia
frameworks, the problem of chipping of the zirconia veneering ceramic has
not been eliminated yet [19, 20]. Consequently, zirconia- based single crowns
should not be considered as the primary treatment option for now, and
patients need to be thoroughly informed about current limitations.

Another factor influencing the choice of the material for single crowns in daily
clinical practice is the biologic outcome of the reconstructions. The present
review indicated, that the biological outcomes of all- ceramic crowns were
significantly better than the ones of metal-ceramics. Less invasive abutment
tooth preparation for the highly esthetic all- ceramic FDPs may be assumed
as reason for the observed differences [21] [22].
Considering the current trend towards less invasive dental rehabilitation, the
biological differences between materials may be considered as one of the key

18
decisive factors for the choice of ceramics as reconstructive material for single
crowns today [21, 22]. Future research should focus on this topic and also
further elucidate the reasons for the biologic differences between all-ceramic
and metal-ceramic reconstructions.

Conclusion

All-ceramic single crowns exhibit similar survival rates as metal- ceramic

single crowns after a mean observation period of at least 3 years. However,
this is solely true for SCs are made out of leucit or lithium-disilicate reinforced
glass ceramics or oxide ceramics. Those materials perform similarly well in
anterior and posterior regions. Crowns made out of densely sintered zirconia,
however, cannot be recommended as primary treatment option, due to an
increased risk of chipping of the veneering ceramic and loss of retention.
These limitations must first be overcome by further refinements of the
production technology. Finally, the mechanically weaker ceramics like the
feldspathic or silica glass- ceramics can only be recommended in anterior
regions with low functional load.

Conflict of interest and acknowledgments

The authors do report to have no conflict of interest.

19
Tables and Figures

20
 Year of No. of patients Drop-out (in
Study Core material Study design Age range Mean age Setting
publication in study percent)

Gehrt et al. 2013 Lithium disilicate glass ceramic prospective 41 34 n.r. University 10%
Monaco et al. 2013 Densely sintered zirconia Retrosp. 398 48.6 18-84 Private practice 0%
Passia et al. 2013 Densely sintered zirconia RCT 123 42.7 24-73 University 37%
Rinke et al. 2013 Densely sintered zirconia Prosp. 53 49.6 29-70 Private practice 8%
Sagitkaya et al. 2012 Densely sintered zirconia RCT 42 n.r. n.r. University 0%
Sorrentino et al. 2012 Densely sintered alumina Retrosp. 112 n.r. 18-69 University 1%
Ortorp et al. 2012 Densely sintered zirconia Retrosp. 169 n.r. n.r. Private practice 32%
Vigolo & Mutinelli 2012 Densely sintered zirconia Prosp. 20 32 19-55 Private practice 3%
Wolleb et al. 2012 Leucit reinforced glass ceramic Retrosp. 52 61.3 34-84 University 14%
Cortellini & Canale 2012 Lithium-disilicate glass ceramic prospective 76 36 20-61 Private practice 0%
Beier et al. 2012 Feldspathic/ silica-based ceramic Retrosp. 302 46.5 n.r. University 0%
Rinke et al. 2011 Glass-infiltrated alumina Retrosp. 80 n.r. n.r. Private practice 0%
Feldspathic/ silica-based ceramic
Cehreli et al. 2011 RCT 33 n.r. n.r. University 0%
glass-infiltrated alumina
Kokubo et al. 2011 Glass-infiltrated alumina prospective 39 50.9 n.r. Private practice 13%
Beuer et al. 2010 Densely sintered zirconia prospective 38 50.9 27-71 University 0%
Schmitt et al. 2010 Densely sintered zirconia Prosp. 10 42.1 n.r. University 10%
Vanoorbeek et al. 2010 Densely sintered alumina Prosp. 130 N.r. 18-70 University 27%
Kokubo et al. 2009 Densely sintered alumina prospective 57 46.4 20-70 University 19%
Valenti & Valenti 2009 Lithium disilicate glass ceramic Retrosp. 146 n.r. n.r. Private practice 1%
Signore et al. 2009 Lithium disilicate glass ceramic Retrosp. 200 37.6 19-66 University 4%
Toksavul & Toman 2007 Lithium disilicate glass ceramic prospective 21 38.3 18-60 University 0%
Burke 2007 Feldspathic/ silica-based ceramic prospective 16 37.5 22-51 University 17%
Glass-infiltrated alumina Feldspathic/ silica-
2006* Prospective n.r. n.r. n.r. Private practice n.r.
Malament et al based ceramic
2001
Leucit reinforced glass ceramic
Galindo et al. 2006 Densely sintered alumina Prospective 50 22-75 n.r. University 22%

Naert et al. 2005 Densely sintered alumina Prospective 165 17-75 57 University 27%

Walter el al. 2005 Densely sintered alumina Prospective 70 n.r. 38.8 University 6%

Marquardt & Strub 2006 Lithium disilicate reinforced glass ceramic Prospective 43 22-65 39.9 University 0%
Glass-infiltrated alumina 29 53 17%
Bindl & Mörmann 2004 Prospective 30-77 University
Feldspathic/ silica-based ceramic
Fradeani & Redemagni 2002 Leucit reinforced glass ceramic Retrospective 59 18-68 41 Private practice 8%

Bindl & Mörmann 2002 Glass-infiltrated alumina Prospective 21 n.r. n.r. University n.r.

Fradeani et al. 2002 Glass-infiltrated alumina Retrospective 13 n.r. 48 Private practice n.r.

van Dijken et al. 2001 Leucit reinforced glass ceramic Prospective 110 26-81 53 University 0%
Feldspathic/ silica-based ceramic 95 n.r. 14%
Scherrer et al. 2001 Prospective n.r. University
Glass-infiltrated alumina
Segal 2001 Glass-infiltrated alumina Retrospective 253 n.r. n.r. Private practice n.r.

Ödmann et al. 2001 Densely sintered alumina Prospective 50 19-79 53 Private practice 18%

McLaren & White 2000 Glass-infiltrated alumina Prospective 107 n.r. n.r. Private practice 10%

Haselton et al. 2000 Glass-infiltrated alumina Retrospective 71 18-77 47.3 University 42%

Edelhoff et al. 2000 Leucit reinforced glass ceramic Retrospective 110 n.r. n.r. University n.r.

Erpenstein et al. 2000 Feldspathic/ silica-based ceramic Retrospective 88 n.r. 40.4 Private practice n.r.

Sjögren et al. 1999 Feldspathic/ silica-based ceramic Retrospective 48 24-69 50.2 Private practice 40%

Sjögren et al. 1999 Leucit reinforced glass ceramic Retrospective 63 34-79 54.7 Private practice 27%

58 n.r. University & Private 3%

Oden et al. 1998 Densely sintered alumina Prospective n.r.
practice
Sorensen et al. 1998 Leucit reinforced glass ceramic Prospective 33 17-69 n.r. University 0%

Studer et al. 1998 Leucit reinforced glass ceramic Prospective 71 n.r. n.r. University 17%

22 42 University & Private 11%

Pröbster 1997 Glass-infiltrated alumina Prospective n.r.
practice
45 44.2 University & Private 0%
Scotti et al. 1995 Glass-infiltrated alumina Prospective n.r.
practice
Hüls 1995 Glass-infiltrated alumina Prospective 92 21-72 44.2 University 11%

Kelsey et al. 1995 Feldspathic/ silica-based ceramic Prospective n.r. n.r. > 19 University 9%

Bieniek 1992 Feldspathic/ silica-based ceramic Retrospective 60 26-30 n.r. University 8%

Cheung et al. 1991 Feldspathic/ silica-based ceramic Retrospective n.r. 17-73 37.7 University 66%

Table 1. - Study and patient characteristics of the reviewed studies for all-
ceramic crowns.
n.r. stands for "not reported"
* updata from 2006 based on personal communication with the senior author.

21
 No. of Drop-out
Year of Study Age
Study Core material patients in Mean age Setting (in
publication design range
study percent)

Passia et al 2013 PFM RCT 100 41 21-64 University 19%

Reitemeier et al. 2013, 2005 PFM Prosp. 95 n.r. 15-65 Private practice 15%

Walton 2013 PFM Retrosp. 670 n.r. 14-81 University 5%

Rinke et al. 2013 PFM Prosp. 53 49.6 29-70 Private practice 8%

Wolleb et al. 2012 PFM Retrosp. 52 61.3 34-84 University 14%

Ortorp et al. 2012 PFM Retrosp. 55 60.1 37-83 Private practice 3%

Vigolo & Mutinelli 2012 PFM Prosp. 20 32 19-55 Private practice 5%

Abou Tara et al. 2011 PFM prospective 39 52.5 n.r. University 3%

Naumannet al. 2011 PFM RCT 52 44 n.r. University 8%

Boeckler et al. 2009 PFM Prosp. 21 49.4 26-67 University 14%

Napankangas et al. 2008 PFM Retrosp. 102 59.6 43-91 University 51%

Gungor et al. 2007 PFM prospective 260 n.r. 28-56 University 23%

Eliasson et al. 2007 PFM Retrosp. 45 n.r. n.r. University 7%

De Backer et al. 2007 PFM Retrosp. 456 41 18-82 University 21%

Brägger et al. 2007 PFM Retrosp. 12 n.r. 19 University 30%

Marklund et al. 2003 PFM Prosp. 18 33-69 51 Private practice 0%

Jokstad & Mjör 1996 PFM Prosp. 61 n.r. n.r. Private practice 35%

Table 2. - Study and patient characteristics of the reviewed studies for metal-
ceramic crowns.
n.r. stands for "not reported"
PFM stands for porcelain fused to metal

Year of Total no. of Mean follow-up No. of failure Total crown Estimated Estimated survival
Study publication crowns time exposure time annual failure rate after 5 years
(per 100 crown years) (in percent)
Metal ceramic
Passia et al. 2013 100 4.3 9 434 2.07 90.2%
Reitemeier et al. 2013 190 9.6 10 1832 0.55 97.3%
Walton 2013 2211 9.2 83 13505 0.61 97.0%
Rinke et al. 2013 50 3 1 146 0.68 96.6%
Wolleb et al. 2012 249 5.3 3 1310 0.23 98.9%
Ortorp et al. 2012 90 4.5 8 408 1.96 90.7%
Vigolo & Mutinelli 2012 20 4.8 0 95 0 100%
Abou Tara et al. 2011 60 3.9 1 235 0.43 97.9%
Naumann et al. 2011 52 3.4 6 176 3.41 84.3%
Boeckler et al. 2009 41 2.8 2 114 1.75 91.6%
Näpänkangas & Raustia 2008 100 18.2 21 1820 1.15 94.4%
Gungor et al. 2007 260 7 7 1400 0.50 97.5%
Eliasson et al. 2007 12 4.3 0 51 0 100%
De Backer et al. 2007 1037 10 116 10370 1.12 94.6%
Brägger et al. 2007 106 17 28 1598 1.75 91.6%
Marklund et al. 2003 42 5 3 190 1.58 92.4%
Jokstad & Mjör 1996 43 10 0 281 0 100%
Total 4663 7.3 298 33965
Summary estimate 0.88 95.7%
(95 % CI) * (0.63-1.22) (94.1%-96.9%)

Feldspathic/ silica-based
ceramic
Beier et al. 2012 470 8.5 39 3995 0.98 95.2%
Cehreli et al. 2011 50 3.3 3 165 1.82 91.3%
Burke 2007 59 3.9 3 187 1.60 92.3%
Malament & Socransky 2006 1061 7.9 177 8407 2.11 90.0%

22
Bindl & Mörmann 2004 18 3.4 1 67 1.49 92.8%
Scherrer et al. 2001 30 3.4 4 102 3.92 82.2%
Erpenstein et al. 2000 173 7 42 1210 3.47 84.1%
Sjögren et al. 1999 98 6.1 13 599 2.17 89.7%
Kelsey et al. 1995 101 4 16 388 4.12 81.4%
Bieniek 1992 164 3.6 8 641 1.25 94.0%
Cheung 1991 34 3.3 5 114 4.39 80.3%
Total 2258 7.0 311 15875
Summary estimate 1.96 90.7%
(95 % CI) * (1.44-2.66) (87.6%-93.0%)

Leucit/ Lithiumdisilicate
reinforced glass ceramic
Gehrt et al. 2013 104 6.6 4 623 0.64 96.8%
Cortellini & Canale 2012 22 3.5 1 78 1.28 93.8%
Valenti & Valenti 2009 263 4.9 6 1283 0.47 97.7%
Signore et al. 2009 538 5.3 8 2851 0.28 98.6%
Toksavul & Toman 2007 79 3.5 1 273 0.37 98.2%
Malament & Socransky 2006 954 3.9 33 3732 0.88 95.7%
Marquardt & Strub 2006 27 3.2 0 105 0 100%
Fradeani & Redemagni 2002 125 7.3 6 908 0.66 96.8%
Edelhoff et al. 2000 250 4.2 5 1048 0.48 97.6%
Sjögren et al. 1999 110 3.6 6 396 1.52 92.7%
Sorensen et al. 1998 75 3 1 224 0.45 97.8%
Studer et al. 1998 142 5 14 710 1.97 90.6%
Total 2689 4.5 85 12231
Summary estimate 0.69 96.6%
(95 % CI) * (0.46-1.05) (94.9%-97.7%)

Glass-infiltrated alumina
Rinke et al. 2011 272 13.5 43 3672 1.17 94.3%
Cehreli et al. 2011 51 3.4 2 172 1.16 94.4%
Kokubo et al. 2011 101 4.6 7 464 1.51 92.7%
Malament & Socransky 2006 312 7.2 34 2235 1.52 92.7%
Bindl & Mörmann 2004 18 3.4 1 67 1.49 92.8%
Bindl & Mörmann 2002 43 3.2 3 142 2.11 90.0%
Fradeani et al. 2002 40 4.2 1 167 0.60 97.1%
Segal 2001 546 3 5 1519 0.33 98.4%
Scherrer et al. 2001 120 3 12 344 3.49 84.0%
McLaren & White 2000 223 3.6 9 811 1.11 94.6%
Haselton et al. 2000 80 3 2 240 0.83 95.9%
Pröbster 1997 135 3.3 4 446 0.90 95.6%
Scotti et al. 1995 63 3.1 1 195 0.51 97.5%
Hüls 1995 335 3 3 1005 0.30 98.5%
Total 2339 4.9 127 11479

Summary estimate 1.11 94.6%

(95 % CI) * (0.81-1.51) (92.7%-96.0%)

Table 3. – Annual failure rates and survival of single crowns (part 1)

23
 Year of Total no. of Mean follow-up No. of failure Total crown Estimated Estimated survival
Study publication crowns time exposure time annual failure rate after 5 years
(in percent) (in percent)
Densely sintered alumina
Vanoorbeek et al. 2010 141 2.7 3 377 0.80 96.1%
Sorrentino et al. 2012 128 5.9 3 760 0.39 98.0%
Kokubo et al. 2009 101 4.4 9 441 2.04 90.3%
Galindo et al. 2006 135 4.6 5 619 0.81 96.0%
Naert et al. 2005 300 3 2 886 0.23 98.9%
Walter el al. 2005 107 6 6 597 1.01 95.1%
Ödmann & Andersson 2001 87 7.6 5 662 0.76 96.3%
Oden et al. 1998 100 5 6 487 1.23 94.0%
Total 1099 4.4 39 4829
Summary estimate 0.81 96.0%
(95 % CI) * (0.51-1.27) (93.8%-97.5%)

Densely sintered zirconia

Monaco et al. 2013 472 3.6 16 1708 0.94 95.4%
Passia et al. 2013 123 3.9 28 483 5.80 74.8%
Rinke et al. 2013 55 3 2 158 1.27 93.9%
Sagitkaya et al. 2012 74 3.9 4 286 1.40 93.2%
Örtorp et al. 2012 216 4.1 19 890 2.13 89.9%
Vigolo & Mutinelli 2012 20 4.4 2 89 2.25 89.4%
Vigolo & Mutinelli 2012 20 4.8 1 96 1.04 94.9%
Beuer et al. 2010 50 2.9 0 146 0 100%
Schmitt et al. 2010 19 3.3 0 62 0 100%
Total 1049 3.7 72 3918
Summary estimate 1.84 91.2%
(95 % CI) * (0.89-3.77) (82.8%-95.6%)

Total 14156 5.8 938 82462

Table 3. – Annual failure rates and survival of single crowns (part 2)

* Based on robust Poisson regression.

24
 Total Mean 5 year survival
Estimated Relative failure
number of Total crown crown summary
Type of SCs annual failure p-value**
recon- exposure time follow-up estimate* rate**
rate*
structions time (95 % CI)

0.88 95.7% 1.00 (Ref.)

Metal-ceramic 4663 33965 7.3
(0.63-1.22) (94.1%-96.9%)
Feldspathic/ silica 1.96 90.7% 2.23
2258 15875 7.0 p< 0.001
based ceramic (1.44-2.66) (87.6%-93.0%) (1.45-3.44)
Leucit or lithium-
disilicate reinforced 0.69 96.6% 0.79
2689 12231 4.5 p=0.373
(0.46-1.05) (94.9%-97.7%) (0.47-1.32)
glass ceramic
Glass- infiltrated 1.11 94.6% 1.26
2339 11479 4.9 p= 0.299
alumina (0.81-1.51) (92.7%-96.0%) (0.81-1.95)
Densely sintered 0.81 96.0% 0.92
1099 4829 4.3 p= 0.761
alumina (0.51-1.27) (93.8%-97.5%) (0.54-1.57)
Densely sintered 1.84 91.2% 2.09
1049 3918 3.7 p=0.055
zirconia (0.89-3.77) (82.8%-95.6%) (0.99-4.45)

Table 4. – Summary of annual failure rates, relative failure rates and survival
estimates for single crowns.
* Based on robust Poisson regression.
** Based on multivariable robust Poisson regression including all types of crown

5 year survival 5 year survival

Total Estimated Estimated
summary Total number summary
Type of crowns number of annual failure annual failure p-value**
estimate* of crowns estimate*
crowns rate* rate*
(95 % CI) (95 % CI)

Anterior Posterior

0.77 96.2% 1.59 92.3%

Overall results 4517 4948
(0.62-0.98) (95.2%-97.0%) (0.99-2.57) (87.9%-95.2%)

0.69* 96.6%* 0.61 97.0%

Metal-ceramic 1215 1263 p=0.564
(0.68-0.71) (96.5%-96.7% (0.41-0.93) (95.5%-98.0%)
Feldspathic/ silica based 1.10 94.6% 2.61 87.8%
1432 1847 p<0.0001
ceramic (0.74-1.63) (92.2%-96.4%) (2.10-3.24) (85.1%-90.0%)

Reinforced glass ceramic 0.50 97.5% 430 1.20 94.2%

1019 p= 0.098
(0.24-1.04) (94.9%-98.8%) (0.55-2.61) (87.8%-97.3%)

Glass- infiltrated alumina 0.74 96.4% 1.22 94.1%

526 672 p=0.050
(0.58-0.94) (95.4%-97.2%) (0.62-2.39) (88.7%-97.0%)

Densely sintered alumina 0.67 96.7% 1.05 94.9%

133 296 p=0.135
(0.42-1.07) (94.8%-97.9%) (0.69-1.61) (92.3%-96.6%)

Densely sintered zirconia 0.29 98.5% 1.02 95.0%

192 440 p<0.0001
(0.19-0.47) (97.7%-99.1%) (0.68-1.54) (92.6%-96.7%)

Table 5. – Annual failure rates and survival estimates of crowns placed

anterior and posterior.
* Based on robust Poisson regression.
** Based on multivariable robust Poisson regression.

25
 Number Estimated Cumulative 5
of abutments annual year
or SCs complication complication Relative compl. Relative compl. Relative compl. Relative compl. Relative compl.
p-value** p-value** p-value** p-value** p-value**
rates* rates* rate** rate** rate** rate** rate**
(95 % CI) (95 % CI)

Feldspathic/ silica based

Metal ceramic Reinforced glass ceramic Glass infiltrated alumina Densely sintered alumina Densely sintered zirconia
ceramic

0.20* 1.0%* 0.60 0.52 2.11 1.33 0.45

Caries on abutments 7730 1.00 (Ref.) p=0.076 p=0.243 p<0.0001 p=0.601 p=0.045
(0.15-0.28) (0.7%-1.4%) (0.34-1.06) (0.18-1.55) (1.45-3.09) (0.46-3.85) (0.20-0.98)
0.08* 0.4%* 0.61 0.10 0.54 0.38 0.27
SCs lost due to caries 11068 1.00 (Ref.) p=0.518 p=0.049 p=0.500 p=0.256 p=0.217
(0.03-0.19) (0.2%-0.9%) (0.13-2.74) (0.01-0.99) (0.09-3.19) (0.07-2.01) (0.03-2.17)
SCs lost due to abutment 0.18* 0.9%* 0.45 0.20 0.35 0.43 0.12
11153 1.00 (Ref.) p=0.069 p=0.009 p=0.040 p=0.224 p=0.024
tooth fracture (0.11-0.28) (0.6%-1.4%) (0.19-1.06) (0.06-0.67) (0.13-0.95) (0.11-1.68) (0.02-0.75)
0.35* 1.8%* 2.22 0.41
Loss of abutment tooth vitality 2494 1.00 (Ref.) p=0.149 p=0.006 0 p<0.0001 n.a n.a n.a n.a
(0.29-0.43) (1.4%-2.1%) (0.75-6.55) (0.21-0.77)
0.40* 2.0%* 271.54 92.38 81.82 93.79 17.20
Framework fracture 10075 1.00 (Ref.) p<0.0001 p<0.0001 p<0.0001 p<0.0001 p=0.033
(0.20-0.82) (1.0%-4.0%) (23.05-3199.23) (8.24-1035.29) (7.80-857.84) (9.46-930.03) (1.26-234.31)
SCs lost due to ceramic 0.13* 0.7%* 1.22 4.06 2.81 4.00 11.36
9144 1.00 (Ref.) p=0.884 p=0.001 p=0.010 p=0.010 p<0.0001
fractures (0.07-0.24) (0.4%-1.2%) (0.08-18.55) (1.81-9.07) (1.28-6.17) (1.39-11.47) (5.40-23.92)
0.43* 2.1%* 0.45 0.56 0.71 1.34 1.19
Ceramic chipping 5499 1.00 (Ref.) p=0.324 p=0.154 p=0.370 p=0.512 p=0.650
(0.29-0.62) (1.5%-3.1%) (0.09-2.20) (0.25-1.25) (0.34-1.49) (0.56-3.17) (0.56-2.54)
0.19* 1.0%* 0.91 1.64 1.09 3.61 7.85
Loss of retention 7594 1.00 (Ref.) p=0.929 p=0.315 p=0.802 p=0.067 p<0.0001
(0.11-0.34) (0.5%-1.7%) (0.12-6.80) (0.62-4.33) (0.54-2.21) (0.91-14.27) (2.67-23.05)
0.15* 0.7%* 0.82 1.04 6.73
Esthetic failures 5671 1.00 (Ref.) p=0.0.761 0 p<0.0001 p=0.944 p<0.0001 0 p<0.0001
(0.08-0.30) (0.4%-1.5%) (0.23-2.94) (0.32-3.45) (2.46-18.36)

Table 6. – Summary of annual complication rates, overall complication estimates and relative complication rates and or single
crowns.
* Based on robust Poisson regression.
** Based on multivariable robust Poisson regression including all types of crowns
 Number Estimated Cumulative Number Estimated Cumulative Number Estimated Cumulative Number Estimated Cumulative Number Estimated Cumulative Number Estimated Cumulative
of annual 5 year of annual 5 year of annual 5 year of annual 5 year of annual 5 year of annual 5 year
abutments complication complication abutments complication complication abutments complication complicatio abutments complication complication abutments complication complication abutments complication complication
Compli-
or rates* rates* or rates* rates* or rates* n or rates* rates* or rates* rates* or rates* rates*
cation
SCs (95 % CI) (95 % CI) SCs (95 % CI) (95 % CI) SCs (95 % CI) rates* SCs (95 % CI) (95 % CI) SCs (95 % CI) (95 % CI) SCs (95 % CI) (95 % CI)
(95 % CI)

Feldspathic/ silica based ceramic Leucit or lithium-disilicate

Metal ceramic SCs Glass infiltrated alumina SCs Densely sintered alumina SCs Densely sintered zirconia SCs
SCs reinforced glass ceramic SCs

Caries on 0.21 1.0% 0.13 0.6% 0.11 0.5% 0.45 2.2% 0.28 1.4% 0.09 0.5%
2908 890 1685 729 592 876
abutments (0.15-0.29) (0.8%-1.4%) (0.07-0.21) (0.4%-1.1%) (0.04-0.33) (0.2%-1.6%) (0.35-0.57) (1.7%-2.8%) (0.09-0.86) (0.5%-4.2%) (0.04-0.2) (0.2%-1.0%)

0.2%
SCs lost due 0.11 0.5% 0.07 0.3% 0.01 0.06% 0.06 0.3% 0.04 0.03 0.1%
4303 1261 1797 1623 1099 (0.006%- 926
to caries (0.03-0.34) (0.2%-1.7%) (0.02-0.19) (0.1%-1.0%) (0.001-0.09) (0.007%-0.4%) (0.01-0.25) (0.07%-1.2%) (0.01-0.15) (0.004-0.19) (0.002%-1.0%)
0.08%)
SCs lost due
0.24 1.2% 0.11 0.6% 0.05 0.2% 0.08 0.4% 0.10 0.5% 0.03 0.1%
to abutment 5276 1088 1628 1077 1099 926
(0.15-0.40) (0.7%-2.0%) (0.05-0.23) (0.3%-1.2%) (0.02-0.15) (0.1%-0.8%) (0.03-0.22) (0.3%-1.1%) (0.03-0.41) (0.1%-2.0%) (0.004-0.19) (0.02%-1.0%)
tooth fracture
Loss of
0.34 1.7% 0.76 3.7% 0.14 0.7%
abutment 1684 375 395 40 0 0% n.a. n.a. n.a. n.a. n.a. n.a.
(0.32-0.36) (1.6%-1.8%) (0.21-2.71) (1.0%-12.7%) (0.07-0.28) (0.3%-1.4%)
tooth vitality

Marginal 0.36 1.8% 0.68 3.3% 0.46 2.3% 2.01 9.6%

345 160 975 322 370 0 0% 670 0. 0%
discoloration (0.14-0.90) (0.7%-4.4%) (0.17-2.74) (0.8%-12.8%) (0.12-1.75) (0.6%-8.4%) (0.49-8.22) (2.4%-33.7%)

0.03%
Framework 0.005 1.38 6.7% 0.47 2.3% 0.42 2.1% 0.48 2.4% 0.09 0.4%
3075 (0.002%- 1261 1952 1703 1099 926
fracture (0.0005-0.05) (0.49-3.90) (2.4%-17.7%) (0.19-1.14) (1.0%-5.5%) (0.21-0.81) (1.1%-4.0%) (0.31-0.73) (1.5%-3.6%) (0.02-0.35) (0.1%-1.7%)
0.3%)
SCs lost due
0.06 0.3% 0.07 0.3% 0.23 1.1% 0.16 0.8% 0.23 1.1% 0.64 3.2%
to ceramic 4457 529 1155 1441 577 926
(0.03-0.11) (0.1%-0.6%) (0.002-1.67) (0.01%-8.0%) (0.15-0.36) (0.7%-1.8%) (0.10-0.24) (0.5%-1.2%) (0.09-0.55) (0.5%-2.7%) (0.47-0.88) (2.3%-4.3%)
fractures

Ceramic 0.53 2.6% 0.24 1.2% 0.30 1.5% 0.38 1.9% 0.71 3.5% 0.64 3.1%
1146 953 1408 594 999 340
chipping (0.27-1.10) (1.3%-5.2%) (0.05-1.15) (0.3%-5.7%) (0.19-0.48) (0.9%-2.4%) (0.27-0.54) (1.3%-2.7%) (0.40-1.29) (2.0%-6.2%) (0.42-1.0) (2.1%-4.7%)

Loss of 0.12 0.6% 0.11 0.6% 0.20 1.0% 0.14 0.7% 0.45 2.2% 0.97 4.7%
2971 823 1583 987 757 414
retention (0.07-0.21) (0.4%-1.0%) (0.01-0.93) (0.07%-4.6%) (0.08-0.49) (0.4%-2.4%) (0.08-0.23) (0.4%-1.2%) (0.11-1.85) (0.5%-8.8%) (0.34-2.81) (1.7%-13.1%)

Esthetic 0.11 0.5% 0.09 0.4% 0.11 0.6% 0.74 3.6%

2806 563 1006 0 0% 282 757 196 0 0%
failures (0.08-0.15) (0.4%-0.8%) (0.02-0.36) (0.1%-1.8%) (0.03-0.46) (0.1%-2.3%) (0.26-2.09) (1.3%-9.9%)

Table 7. – Overview of biological and technical complications of different types of SCs.

• * Based on robust Poisson regression.

n.a. stands for “not available”

27
 First electronic search
580 Titles

Independently selected by 2 reviewers

71 titles

Agreed by both
71 titles
Abstracts obtained

Discussion
Agreed on 71 abstracts
Full text obtained

Total full text articles for the

Further hand searching “multiple- unit fixed dental
0 studies
prosthesis” review
37
Total full text articles for “single crown review” (number includes also studies reporting
on crowns and bridges at the same time)
41
Total full text articles
Exclusion of 8 studies
For details see reference list of excluded included from previous
literature single crowns” review[1]
34
+
Final number of studies included
= Total of included
33
studies in present review
67

Figure 1. - Search strategy and included studies on single crowns

28
Fig. 2 – Annual failure rate of metal ceramic SCs.

29
Fig. 3 – Annual failure rate of feldspathic/ silica based ceramic SCs.

30
Fig. 4 – Annual failure rate of leucit or lithium-disilicate reinforced glass
ceramic SCs.

31
Fig. 5 – Annual failure rate of glass infiltrated alumina SCs.

32
Fig. 6 – Annual failure rate of densely sintered alumina ceramic SCs.

33
Fig. 7 – Annual failure rate of densely sintered zirconia ceramic SCs.

34
References – included literature

[1] Pjetursson BE, Sailer I, Zwahlen M, Hammerle CH. A systematic review of

the survival and complication rates of all-ceramic and metal-ceramic
reconstructions after an observation period of at least 3 years. Part I: Single
crowns. Clinical oral implants research. 2007;18 Suppl 3:73-85.
[2] Sailer I, Pjetursson BE, Zwahlen M, Hammerle CH. A systematic review of
the survival and complication rates of all-ceramic and metal-ceramic
reconstructions after an observation period of at least 3 years. Part II: Fixed
dental prostheses. Clinical oral implants research. 2007;18 Suppl 3:86-96.
[3] Edelhoff D, Brix O. All-ceramic restorations in different indications: a case
series. Journal of the American Dental Association. 2011;142 Suppl 2:14S-
9S.
[4] Walton TR. Making sense of complication reporting associated with fixed
dental prostheses. The International journal of prosthodontics. 2014;27:114-8.
[5] Raigrodski AJ, Chiche GJ, Potiket N, Hochstedler JL, Mohamed SE, Billiot
S, et al. The efficacy of posterior three-unit zirconium-oxide-based ceramic
fixed partial dental prostheses: a prospective clinical pilot study. The Journal
of prosthetic dentistry. 2006;96:237-44.
[6] Kirkwood BR, Sterne JAC. Medical Statistics, Chapter 24: Poisson
Regression Oxford: Blackwell Science Ltd. 2003.
[7] Kirkwood BR, Sterne JAC. Essential Medical Statistics, Chapter 26:
Survival Analysis: Displaying and Comparing Survival Patterns Oxford:
Blackwell Science Ltd. 2003.
[8] Passia N, Stampf S, Strub JR. Five-year results of a prospective
randomised controlled clinical trial of posterior computer-aided design-
computer-aided manufacturing ZrSiO4 -ceramic crowns. Journal of oral
rehabilitation. 2013;40:609-17.
[9] Cehreli MC, Kokat AM, Ozpay C, Karasoy D, Akca K. A randomized
controlled clinical trial of feldspathic versus glass-infiltrated alumina all-
ceramic crowns: a 3-year follow-up. The International journal of
prosthodontics. 2011;24:77-84.
[10] Naumann M, Ernst J, Reich S, Weisshaupt P, Beuer F. Galvano- vs.
metal-ceramic crowns: up to 5-year results of a randomised split-mouth study.
Clinical oral investigations. 2011;15:657-60.
[11] Sax C, Hammerle CH, Sailer I. 10-year clinical outcomes of fixed dental
prostheses with zirconia frameworks. International journal of computerized
dentistry. 2011;14:183-202.
[12] Sailer I, Gottnerb J, Kanelb S, Hammerle CH. Randomized controlled
clinical trial of zirconia-ceramic and metal-ceramic posterior fixed dental
prostheses: a 3-year follow-up. The International journal of prosthodontics.
2009;22:553-60.
[13] Schley JS, Heussen N, Reich S, Fischer J, Haselhuhn K, Wolfart S.
Survival probability of zirconia-based fixed dental prostheses up to 5 yr: a
systematic review of the literature. European journal of oral sciences.
2010;118:443-50.
[14] Heintze SD, Rousson V. Survival of zirconia- and metal-supported fixed
dental prostheses: a systematic review. The International journal of
prosthodontics. 2010;23:493-502.

35
[15] Gherlone E, Mandelli F, Cappare P, Pantaleo G, Traini T, Ferrini F. A 3
years retrospective study of survival for zirconia-based single crowns
fabricated from intraoral digital impressions. J Dent. 2014.
[16] Koenig V, Vanheusden AJ, Le Goff SO, Mainjot AK. Clinical risk factors
related to failures with zirconia-based restorations: an up to 9-year
retrospective study. J Dent. 2013;41:1164-74.
[17] Edelhoff D, Sorensen JA. Tooth structure removal associated with
various preparation designs for anterior teeth. The Journal of prosthetic
dentistry. 2002;87:503-9.
[18] Edelhoff D, Sorensen JA. Tooth structure removal associated with
various preparation designs for posterior teeth. Int J Periodontics Restorative
Dent. 2002;22:241-9.

Newly included further literature, as given in Tables

[1] Pjetursson BE, Sailer I, Zwahlen M, Hammerle CH. A systematic review of the
survival and complication rates of all-ceramic and metal-ceramic reconstructions after
an observation period of at least 3 years. Part I: Single crowns. Clinical oral implants
research. 2007;18 Suppl 3:73-85.
[2] Sailer I, Pjetursson BE, Zwahlen M, Hammerle CH. A systematic review of the
survival and complication rates of all-ceramic and metal-ceramic reconstructions after
an observation period of at least 3 years. Part II: Fixed dental prostheses. Clinical oral
implants research. 2007;18 Suppl 3:86-96.
[3] Edelhoff D, Brix O. All-ceramic restorations in different indications: a case series.
Journal of the American Dental Association. 2011;142 Suppl 2:14S-9S.
[4] Walton TR. Making sense of complication reporting associated with fixed dental
prostheses. The International journal of prosthodontics. 2014;27:114-8.
[5] Raigrodski AJ, Chiche GJ, Potiket N, Hochstedler JL, Mohamed SE, Billiot S, et
al. The efficacy of posterior three-unit zirconium-oxide-based ceramic fixed partial
dental prostheses: a prospective clinical pilot study. The Journal of prosthetic
dentistry. 2006;96:237-44.
[6] Kirkwood BR, Sterne JAC. Medical Statistics, Chapter 24: Poisson Regression
Oxford: Blackwell Science Ltd. 2003.
[7] Kirkwood BR, Sterne JAC. Essential Medical Statistics, Chapter 26: Survival
Analysis: Displaying and Comparing Survival Patterns Oxford: Blackwell Science
Ltd. 2003.
[8] Passia N, Stampf S, Strub JR. Five-year results of a prospective randomised
controlled clinical trial of posterior computer-aided design-computer-aided
manufacturing ZrSiO4 -ceramic crowns. Journal of oral rehabilitation. 2013;40:609-
17.
[9] Cehreli MC, Kokat AM, Ozpay C, Karasoy D, Akca K. A randomized controlled
clinical trial of feldspathic versus glass-infiltrated alumina all-ceramic crowns: a 3-
year follow-up. The International journal of prosthodontics. 2011;24:77-84.
[10] Naumann M, Ernst J, Reich S, Weisshaupt P, Beuer F. Galvano- vs. metal-
ceramic crowns: up to 5-year results of a randomised split-mouth study. Clinical oral
investigations. 2011;15:657-60.
[11] Wolleb K, Sailer I, Thoma A, Menghini G, Hammerle CH. Clinical and
radiographic evaluation of patients receiving both tooth- and implant-supported
prosthodontic treatment after 5 years of function. The International journal of
prosthodontics. 2012;25:252-9.

36
[12] Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations
over 20 years: Part IV. The effects of combinations of variables. The International
journal of prosthodontics. 2010;23:134-40.
[13] Ortorp A, Kihl ML, Carlsson GE. A 3-year retrospective and clinical follow-up
study of zirconia single crowns performed in a private practice. J Dent. 2009;37:731-
6.
[14] Rinke S, Schafer S, Lange K, Gersdorff N, Roediger M. Practice-based clinical
evaluation of metal-ceramic and zirconia molar crowns: 3-year results. Journal of oral
rehabilitation. 2013;40:228-37.
[15] Sax C, Hammerle CH, Sailer I. 10-year clinical outcomes of fixed dental
prostheses with zirconia frameworks. International journal of computerized dentistry.
2011;14:183-202.
[16] Sailer I, Gottnerb J, Kanelb S, Hammerle CH. Randomized controlled clinical
trial of zirconia-ceramic and metal-ceramic posterior fixed dental prostheses: a 3-year
follow-up. The International journal of prosthodontics. 2009;22:553-60.
[17] Schley JS, Heussen N, Reich S, Fischer J, Haselhuhn K, Wolfart S. Survival
probability of zirconia-based fixed dental prostheses up to 5 yr: a systematic review of
the literature. European journal of oral sciences. 2010;118:443-50.
[18] Heintze SD, Rousson V. Survival of zirconia- and metal-supported fixed dental
prostheses: a systematic review. The International journal of prosthodontics.
2010;23:493-502.
[19] Gherlone E, Mandelli F, Cappare P, Pantaleo G, Traini T, Ferrini F. A 3 years
retrospective study of survival for zirconia-based single crowns fabricated from
intraoral digital impressions. J Dent. 2014.
[20] Koenig V, Vanheusden AJ, Le Goff SO, Mainjot AK. Clinical risk factors related
to failures with zirconia-based restorations: an up to 9-year retrospective study. J
Dent. 2013;41:1164-74.
[21] Edelhoff D, Sorensen JA. Tooth structure removal associated with various
preparation designs for anterior teeth. The Journal of prosthetic dentistry.
2002;87:503-9.
[22] Edelhoff D, Sorensen JA. Tooth structure removal associated with various
preparation designs for posterior teeth. Int J Periodontics Restorative Dent.
2002;22:241-9.

List of excluded full-text articles and the reason for exclusion

[1] Mansour YF, Al-Omiri MK, Khader YS, Al-Wahadni A. (2008) Clinical
performance of IPS-Empress 2 ceramic crowns inserted by general dental
practitioners. The Journal of Contemporary Dental Practice. 9(4):9-16.
Exclusion criteria: mean follow-up time < 3 years

[2]Cagidiaco MC, García-Godoy F, Vichi A, Grandini S, Goracci C, Ferrari M.

(2008) Placement of fiber prefabricated or custom made posts affects the 3-
year survival of endodontically treated premolars. American Journal of
Dentistry. 21(3):179-84.
Exclusion criteria: no specific information on crown material and no detailed
outcomes

37
[3]Ortorp A, Kihl ML, Carlsson GE. (2009) A 3-year retrospective and clinical
follow-up study of zirconia single crowns performed in a private practice.
Journal of Dentistry. 37(9):731-6.
Exclusion criteria: multiple publication of the same patient cohort

[4]Walton TR. (2009) Changes in the outcome of metal-ceramic tooth-

supported single crowns and FDPs following the introduction of
osseointegrated implant dentistry into a prosthodontic practice. The
International Journal of Prosthodontics. 22(3):260-7.
Exclusion criteria: multiple publication of the same patient cohort

[5]Burke FJ, Lucarotti PS. (2009) Ten-year outcome of crowns placed within
the General Dental Services in England and Wales. Journal of Dentistry.
37(1):12-24.
Exclusion criteria: based on a chart review

[6]Groten M, Huttig F. (2010) The performance of zirconium dioxide crowns: a

clinical follow-up. The International Journal of Prosthodontics. 23(5):429-31.
Exclusion criteria: mean follow-up time < 3 years

[7]Rinke S, Schäfer S, Roediger M. (2011) Complication rate of molar crowns:

a practice-based clinical evaluation. International Journal of Computerized
Dentistry. 14(3):203-18.
Exclusion criteria: mean follow-up time < 3 years

[8]Silva NR, Thompson VP, Valverde GB, Coelho PG, Powers JM, Farah JW,
Esquivel-Upshaw J. (2011) Comparative reliability analyses of zirconium
oxide and lithium disilicate restorations in vitro and in vivo. Journal of the
American Dental Association (1939). 142 Suppl 2:4S-9S.
Exclusion criteria: data not specified between implant and tooth abutments,
single crowns and bridges

38